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Introduction to the ISA


ISA Publications


Interoperability for COVID-19 Novel Coronavirus Pandemic


Comment

Standards Version Advancement Process (SVAP)


Current Standard / Implementation Specification listing in IBR (170.299) Regulatory Text Citation for Standard / Implementation Specification Adopted Sort descending Certification Criteria(on) References Standard / Implementation Specification National Coordinator Approved Advanced Version(s)
Applicability Statement for Secure Health Transport, Version 1.2, August 2015 (Direct) § 170.202(a)(2)
§ 170.315(b)(1) - Transitions of care
§ 170.315(h)(1) - Direct Project
§ 170.315(h)(2) - Direct Project, Edge Protocol, and XDR/XDM
XDR and XDM for Direct Messaging Specification, Version 1, March 9, 2011 § 170.202(b)
§ 170.315(h)(2) - Direct Project, Edge Protocol, and XDR/XDM
ONC Implementation Guide for Direct Edge Protocols, Version 1.1, June 25, 2014 § 170.202(d)
§ 170.315(b)(1) - Transitions of care
§ 170.315(h)(2) - Direct Project, Edge Protocol, and XDR/XDM
Implementation Guide for Delivery Notification in Direct, Version 1.0, June 29, 2012 § 170.202(e)(1)
§ 170.315(h)(1) - Direct Project
§ 170.315(h)(2) - Direct Project, Edge Protocol, and XDR/XDM
Web Content Accessibility Guidelines (WCAG) 2.0, December 11, 2008 § 170.204(a)(1)
§ 170.315(e)(1) - View, download, and transmit to 3rd party
Web Content Accessibility Guidelines (WCAG) 2.0, December 11, 2008 § 170.204(a)(2)
§ 170.315(e)(1) - View, download, and transmit to 3rd party
HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation, DSTU Release 1.1 (US Realm) Draft Standard for Trial Use July 2012 § 170.205(a)(3)
§ 170.315(b)(1) - Transitions of care
§ 170.315(b)(2) - Clinical information reconciliation and incorporation
HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm), Draft Standard for Trial Use, Volume 1 - Introductory Material, Release 2.1, August 2015 § 170.205(a)(4)
§ 170.315(b)(1) - Transitions of care
§ 170.315(b)(2) - Clinical information reconciliation and incorporation
§ 170.315(b)(6) - Data export
§ 170.315(b)(7) - Security tags – summary of care – send
§ 170.315(b)(8) - Security tags – summary of care – receive
§ 170.315(b)(9) - Care plan
§ 170.315(e)(1) - View, download, and transmit to 3rd party
§ 170.315(f)(5) - Transmission to public health agencies - electronic case reporting
§ 170.315(g)(9) - Application access - all data request
HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm), Draft Standard for Trial Use, Volume 2 - Templates and Supporting Material, Release 2.1, August 2015 § 170.205(a)(4)
§ 170.315(b)(1) - Transitions of care
§ 170.315(b)(2) - Clinical information reconciliation and incorporation
§ 170.315(b)(6) - Data export
§ 170.315(b)(7) - Security tags – summary of care – send
§ 170.315(b)(8) - Security tags – summary of care – receive
§ 170.315(b)(9) - Care plan
§ 170.315(e)(1) - View, download, and transmit to 3rd party
§ 170.315(f)(5) - Transmission to public health agencies - electronic case reporting
§ 170.315(g)(9) - Application access - all data request
HL7® CDA R2 Implementation Guide: C-CDA Templates for Clinical Notes R2.1 Companion Guide, Release 2-US Realm, October 2019 § 170.205(a)(5)
§ 170.315(b)(1) - Transitions of care
§ 170.315(b)(2) - Clinical information reconciliation and incorporation
§ 170.315(b)(9) - Care plan
§ 170.315(e)(1) - View, download, and transmit to 3rd party
§ 170.315(f)(5) - Transmission to public health agencies - electronic case reporting
§ 170.315(g)(9) - Application access - all data request
NCPDP SCRIPT Standard, Implementation Guide, Version 2017071 (Approval Date for ANSI: July 28, 2017) § 170.205(b)(1)
§ 170.315(b)(3) - Electronic prescribing
CDC PHIN Messaging Guide for Syndromic Surveillance: Emergency Department, Urgent Care, Inpatient and Ambulatory Care Settings, Release 2.0, April 21, 2015 § 170.205(d)(4)
§ 170.315(f)(2) - Transmission to public health agencies — syndromic surveillance
Erratum to the CDC PHIN 2.0 Implementation Guide, August 2015; Erratum to the CDC PHIN 2.0 Messaging Guide, April 2015 Release for Syndromic Surveillance: Emergency Department, Urgent Care, Inpatient and Ambulatory Care Settings § 170.205(d)(4)
§ 170.315(f)(2) - Transmission to public health agencies — syndromic surveillance
HL7 2.5.1 Implementation Guide for Immunization Messaging, Release 1.5, October 1, 2014 § 170.205(e)(4)
§ 170.315(f)(1) - Transmission to immunization registries
HL7 Version 2.5.1 Implementation Guide for Immunization Messaging (Release 1.5) - Addendum, July 2015 § 170.205(e)(4)
§ 170.315(f)(1) - Transmission to immunization registries
HL7 v2.5.1 IG: Electronic Laboratory Reporting to Public Health (US Realm), Release 1 Errata and Clarifications, September, 29, 2011 § 170.205(g)
§ 170.315(f)(3) - Transmission to public health agencies — reportable laboratory tests and value/results
ELR 2.5.1 Clarification Document for EHR Technology Certification, July 16, 2012 § 170.205(g)
§ 170.315(f)(3) - Transmission to public health agencies — reportable laboratory tests and value/results
HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture - Category I (QRDA I); Release 1, DSTU Release 3 (US Realm), Volume 1 - Introductory Material, June 2015 § 170.205(h)(2)
§ 170.315(c)(1) - Clinical quality measures (CQMs) — record and export
§ 170.315(c)(2) - Clinical quality measures (CQMs) — import and calculate
HL7 CDA R2 Implementation Guide: Quality Reporting Document Architecture - Category I (QRDA I); Release 1, DSTU Release 3 (US Realm), Volume 2 - Templates and Supporting Material, June 2015 § 170.205(h)(2)
§ 170.315(c)(1) - Clinical quality measures (CQMs) — record and export
§ 170.315(c)(2) - Clinical quality measures (CQMs) — import and calculate
CMS Implementation Guide for Quality Reporting Document Architecture: Category I; Hospital Quality Reporting; Implementation Guide for 2019 § 170.205(h)(3)
§ 170.315(c)(3) - Clinical quality measures (CQMs) — report
HL7 CDA© Release 2 Implementation Guide: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, Release 1; DSTU Release 1.1 (US Realm), Volume 1 - Introductory Material, April 2015 § 170.205(i)(2)
§ 170.315(f)(4) - Transmission to cancer registries
HL7 CDA© Release 2 Implementation Guide: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, Release 1; DSTU Release 1.1 (US Realm), Volume 2 - Templates and Supporting Material, April 2015 § 170.205(i)(2)
§ 170.315(f)(4) - Transmission to cancer registries
CMS Implementation Guide for Quality Reporting Document Architecture: Category III; Eligible Clinicians and Eligible Professionals Programs; Implementation Guide for 2019 § 170.205(k)(3)
§ 170.315(c)(3) - Clinical quality measures (CQMs) — report
HL7 Version 3 Implementation Guide: Data Segmentation for Privacy (DS4P), Release 1, Part 1: CDA R2 and Privacy Metadata Reusable Content Profile, May 16, 2014 § 170.205(o)(1)
§ 170.315(b)(7) - Security tags – summary of care – send
§ 170.315(b)(8) - Security tags – summary of care – receive
IHE IT Infrastructure Technical Framework Volume 2b (ITI TF-2b), Transactions Part B - Sections 3.29 - 2.43, Revision 7.0, August 10, 2010 § 170.205(p)(1)
§ 170.315(b)(1) - Transitions of care
HL7 Implementation Guide for CDA® Release 2 - Level 3: Healthcare Associated Infection Reports, Release 1 (U.S. Realm), August 9, 2013 § 170.205(r)(1)
§ 170.315(f)(6) - Transmission to public health agencies — antimicrobial use and resistance reporting
HL7 Implementation Guide for CDA® Release 2: National Health Care Surveys (NHCS), Release 1 - US Realm, HL7 Draft Standard for Trial Use, Volume 1 - Introductory Material, December 2014 § 170.205(s)(1)
§ 170.315(f)(7) - Transmission to public health agencies — health care surveys
HL7 Implementation Guide for CDA® Release 2: National Health Care Surveys (NHCS), Release 1 - US Realm, HL7 Draft Standard for Trial Use, Volume 2 - Templates and Supporting Material, December 2014 § 170.205(s)(1)
§ 170.315(f)(7) - Transmission to public health agencies — health care surveys
United States Core Data for Interoperability (USCDI), Version 1, February 2020 § 170.213
§ 170.315(b)(1) - Transitions of care
§ 170.315(b)(2) - Clinical information reconciliation and incorporation
§ 170.315(e)(1) - View, download, and transmit to 3rd party
§ 170.315(f)(5) - Transmission to public health agencies - electronic case reporting
§ 170.315(g)(9) - Application access - all data request
§ 170.315(g)(10) - Standardized API for patient and population services
HL7 Fast Healthcare Interoperability Resources Specification (FHIR®) Release 4, Version 4.0.1: R4, October 30, 2019, including Technical Correction #1, November 1, 2019 § 170.215(a)(1)
§ 170.315(g)(10) - Standardized API for patient and population services
HL7 FHIR® US Core Implementation Guide STU 3.1.0, November 06, 2019 § 170.215(a)(2)
§ 170.315(g)(10) - Standardized API for patient and population services
HL7 FHIR® SMART Application Launch Framework Implementation Guide Release 1.0.0, November 13, 2018 § 170.215(a)(3)
§ 170.315(g)(10) - Standardized API for patient and population services
HL7 FHIR® Bulk Data Access (Flat FHIR®) (v1.0.0: STU 1), August 22, 2019 § 170.215(a)(4)
§ 170.315(g)(10) - Standardized API for patient and population services
OpenID Connect Core 1.0 Incorporating errata set 1, November 8, 2014, IBR approved for § 170.215(b) § 170.215(b)
§ 170.315(g)(10) - Standardized API for patient and population services

1SVAP is permitted in ONC’s 21st Century Cures Act Final Rule in the Real World Testing CoC/MoC: § 170.405(b)(7) and (8) and ONC-ACB PoPC  §170.523(t)

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United States Core Data for Interoperability (USCDI)


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Table of Contents


Imaging (Diagnostics, Interventions and Procedures)

Patient Clinical “Problems” (i.e., conditions)

Family Health History (Clinical Genomics)

Medical Device Communication to Other Information Systems/Technologies

Patient Identification Management

Segmentation of sensitive information

Healthcare Directory, Provider Directory

2020 ISA Reference Edition


Structure


Timeline and Comment Process


FAQs



Section I

Allergies and Intolerances

Representing Patient Allergic Reactions


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Allergic Reactions. The Allergy and Clinical Immunology CPT codes (95004 – 95199) identify patient assessment and intervention for allergy testing, ingestion challenge testing, and allergen immunotherapy. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Patient Allergies and Intolerances; Environmental Substances


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Allergies and Intolerances; Environmental Substances. The Allergy and Clinical Immunology CPT codes (95004 – 95199) identify patient assessment and intervention for allergy testing and allergen immunotherapy, including environmental substances. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Patient Allergies and Intolerances; Food Substances


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Allergies and Intolerances; Food Substances. The Allergy and Clinical Immunology CPT codes (95004 – 95199) identify patient assessment and intervention for allergy testing, ingestion challenge testing, and allergen immunotherapy, including food substances. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Patient Allergies and Intolerances; Medications


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Allergies and Intolerances; Medications. The Allergy and Clinical Immunology CPT codes (95004 – 95199) identify patient assessment and intervention for allergy testing, ingestion challenge testing, and allergen immunotherapy, including medications. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Clinical Notes

Representing Clinical Notes


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Cognitive Status

Representing Patient Cognitive Status


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Cognitive Status. The CPT code set contains Evaluation and Management code 99483, which identifies a comprehensive cognitive assessment of the patient, including, but not limited to:
  • Cognition-focused evaluation,
  • Functional assessment, including decision-making capacity,
  • Use of standardized instruments for staging of dementia,
  • Evaluation of safety,
  • Identification of caregivers, and
  • Creation of a written care plan.
CPT codes 96105-96146 identify neuro-cognitive assessments and tests, including cognitive performance testing, interactive feedback, neurobehavioral status examination, and neuropsychological testing evaluation services. Cognitive skills are also identified in the Occupational Therapy Evaluations codes, 97165 – 97167, and Therapeutic Procedures, 97129. In addition, CPT Category II codes 3720F and 3755F identify assessment and screening for cognitive impairment or dysfunction within the treatment of other clinical conditions. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Demographics

Representing Patient Contact Information for Telecommunications


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Representing Nutrition Assessment, Diagnosis, Interventions and Monitoring/Evaluation


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Nutrition Assessment, Diagnosis, Interventions and Monitoring/Evaluation. CPT codes 97802 – 97804 identify patient assessment and intervention of medical nutrition therapy. In addition, CPT Category II codes 3759F and 3760F identify assessment and screening for nutrition within the treatment of another clinical condition. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Emergency Medical Services

Representing Health Care Data for Emergency Medical Services


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Health Care Data for Emergency Medical Services. CPT codes 99281 – 99285 identify patient evaluation, examination, and medical decision making for emergency department services. CPT code 99288 identifies the direction of emergency care to emergency medical services personnel by a physician or other qualified health care professional. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Encounter Diagnosis, Assessment and Plan

Representing Assessment and Plan of Treatment


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Assessment and Plan of Treatment. The CPT Evaluation and Management codes specifically address multiple categories and subcategories for the broad range and levels of assessing and planning treatment for the patient. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Patient Dental Encounter Diagnosis


Comment

Representing Patient Medical Encounter Diagnosis


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Family Health History

Representing Patient Family Health History


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Family Health History. The CPT Evaluation and Management codes specifically address capturing the patient’s family health history. The E/M codes specifically provide information about:
  • The health status or cause of death of parents, siblings, and children;
  • Specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review
  • Diseases of family members that may be hereditary or place the patient at risk
Also, CPT code 96040 identifies medical genetics and genetic counseling services. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Functional Status/Disability

Representing Patient Functional Status and/or Disability


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Functional Status and/or Disability. CPT codes 99455 and 99456 identify the completion of medical history, examination, diagnosis, development of a treatment plan, and completion of necessary documents for a patient with a work related or medical disability.  Functional status and disability are also identified in the Physical Therapy Evaluations codes, 97161 – 97164, and Occupational Therapy Evaluations codes, 97165 – 97167, which include patient history, examination, clinical decision making, and development of a treatment plan. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Goals

Representing Patient Goals


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Goals. CPT Category II codes for Health and Well-Being Coaching (0591T – 0593T) identify services for goal setting, education, and monitoring related to those goals.   CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Health Care Providers, Family Members, and Other Caregivers

Representing Health Care Providers


Comment

Representing Provider Role in Team Care Settings


Comment

Representing Relationship Between Patient and Another Person


Comment

Imaging (Diagnostics, Interventions and Procedures)

Representing Imaging Diagnostics, Interventions and Procedures


Comment

Immunizations

Representing Immunizations – Administered


Comment

Representing Immunizations – Historical


Comment

Industry and Occupation

Representing Patient Industry and Occupation


Comment

Laboratory

Representing Laboratory Tests


Comment

Representing Laboratory Values/Results


Comment

Medications

Representing Patient Medications


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Nursing

Representing Clinical/Nursing Assessments


Comment

Representing Nursing Interventions


Comment

Representing Outcomes for Nursing


Comment

Representing Patient Problems for Nursing


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Patient Clinical “Problems” (i.e., conditions)

Representing Patient Clinical “Problems” (i.e., Conditions)


Comment

Preferred Language

Representing Patient Preferred Language (Presently)


Comment

Pregnancy Status

Representing Patient Pregnancy Status


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Procedures

Representing Dental Procedures Performed


Comment

Representing Medical Procedures Performed


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Provenance

Representing Data Provenance


Comment

Race and Ethnicity

Representing Patient Race and Ethnicity


Comment

Research

Representing Data for Biomedical and Health Services Research Purposes


Comment

Sex at Birth, Sexual Orientation and Gender Identity

Representing Patient Gender Identity


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Gender Identity. CPT code 55970 identifies an intersex surgery of male to female. CPT code 55980 identifies an intersex surgery of female to male. Evaluation and Management codes for a new patient (99381) and established patient (99391) include completing a gender appropriate history, exam, counseling and interventions. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Patient Sex (At Birth)


Comment

Representing Patient-Identified Sexual Orientation


Comment

Social, Psychological, and Behavioral Data

Representing Alcohol Use


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Alcohol Use. CPT codes 99408 and 99409 identify patient screening and intervention for alcohol abuse. CPT codes 8032-80322 identify testing for alcohol. CPT code 82075 identifies an alcohol breath test. In addition, CPT Category II codes identify a patient screened for unhealthy alcohol use (3016F), patient counseled about risks of alcohol use (4158F), and patient counseled for pharmacologic treatment for alcohol dependence (4320F). CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Depression


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Depression. CPT code 96127 identifies patient screening through a behavioral assessment for depression.  CPT code 99483 includes an assessment for depression within the cognitive care plan.  CPT code 96127 includes an assessment for depression with this developmental/behavioral screening and testing. In addition, CPT Category II code 1040F, 2060F, and 3088F – 3093F identify evaluations of major depressive disorder. CPT Category II codes 1220F, 3351F – 3354F, 3725F identify a patient screened for depression within the treatment of other clinical conditions. CPT Category II codes 4060F – 4067F identify various services provided depression. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Drug Use


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Drug Use. CPT codes 99408 and 99409 identify patient screening and intervention for substance abuse. CPT codes 80320 – 80377 identify definitive drug testing. In addition, CPT Category II codes identify a patient screened for injection drug use (4290F) and counseled for pharmacologic treatment for opioid addiction (4306F). CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Exposure to Violence (Intimate Partner Violence)


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Exposure to Violence (Intimate Partner Violence). The CPT Evaluation and Maintenance services include assessing a patient’s risk and exposure to violence. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Financial Resource Strain


Comment

Representing Food Insecurity


Comment

Representing Housing Insecurity


Comment

Representing Level of Education


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Level of Education. The CPT Evaluation and Maintenance services include assessing a patient’s level of education. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Physical Activity


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Physical Activity. Physical activity is identified in the Physical Therapy Evaluations codes, 97161 – 97164, and Occupational Therapy Evaluations codes, 97165 – 97167. CPT codes 97169 – 97172 identify athletic training evaluations, which includes a physical activity profile. The CPT Evaluation and Maintenance services include assessing a patient’s level of physical activity. CPT codes 97750 and 97755 identify tests and measurements of physical performance. In addition, CPT Category II code 1003F identifies an assessment of patient level of activity. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Social Connection and Isolation


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Social Connection and Isolation. The CPT Evaluation and Maintenance services include assessing a patient’s social history. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Stress


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Stress. The CPT codes 90839 and 90840 are used to identify psychotherapy for a crisis. Also, the CPT Evaluation and Maintenance services include assessing a patient’s level of stress. CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Tobacco Use

Representing Patient Electronic Cigarette Use (Vaping)


Comment

Representing Patient Second Hand Tobacco Smoke Exposure


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Second Hand Tobacco Smoke Exposure. CPT Category II code 1032F identifies a patient who is a current smoker or currently exposed to secondhand smoke.   CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Representing Patient Tobacco Use (Smoking Status)


Comment

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Tobacco Use (Smoking Status). CPT codes 99406 and 99407 identify the patient as a tobacco user and that cessation counseling was provided. In addition, CPT Category II codes identify assessment of tobacco use (1000F), current tobacco user with asthma (1032F), current tobacco user with heart disease (1034F), tobacco use cessation counseling (4000F), tobacco use cessation pharmacologic therapy (4001F), and patient screened as a tobacco user and received cessation intervention (4004F). CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

Units of Measure

Representing Units of Measure (For Use with Numerical References and Values)


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Vital Signs

Representing Patient Vital Signs


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Section II

Admission, Discharge, and Transfer

Sending a Notification of a Long Term Care Patient’s Admission, Discharge and/or Transfer Status to the Servicing Pharmacy


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Sending a Notification of a Patient’s Admission, Discharge and/or Transfer Status to Other Providers


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Care Coordination for Referrals

Referral from Acute Care to a Skilled Nursing Facility


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Referral to a Specialist - Request, Status Updates, Outcome


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Referral to Extra-Clinical Services - Request, Updates, Outcome


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Care Plan

Documenting and Sharing Care Plans for a Single Clinical Context


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Documenting and Sharing Medication-Related Care Plans by Pharmacists


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Documenting Care Plans for Person Centered Services


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Domain or Disease-Specific Care Plan Standards


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Sharing Patient Care Plans for Multiple Clinical Contexts


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Clinical Decision Support

Communicate Appropriate Use Criteria with the Order and Charge to the Filling Provider and Billing System for Inclusion on Claims


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Provide Access to Appropriate Use Criteria


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Sharable Clinical Decision Support


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Clinical Quality Measurement and Reporting

Reporting Aggregate Quality Data for Quality Reporting Initiatives


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Reporting Patient-level Quality Data for Quality Reporting Initiatives


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Sharing Quality Measure Artifacts for Quality Reporting Initiatives


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Data Provenance

Establishing the Authenticity, Reliability, and Trustworthiness of Content Between Trading Partners


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Diet and Nutrition

Exchanging Diet and Nutrition Orders Across the Continuum of Care


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Drug Formulary & Benefits

Allows Pharmacy Benefit Payers to Communicate Formulary and Benefit Information to Prescriber Systems


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Electronic Prescribing

Allows a Long Term or Post-Acute Care to Request to Send an Additional Supply of Medication


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Allows a Pharmacy to Notify a Prescriber of Prescription Fill Status


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Allows a Pharmacy to Request a Change to a Prescription


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Allows a Pharmacy to Request a New Prescription For a New Course of Therapy or to Continue Therapy


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Allows a Pharmacy to Request Additional Refills


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Allows a Pharmacy to Request, Respond to, or Confirm a Prescription Transfer


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Allows a Prescriber or a Pharmacy to Request a Patient’s Medication History


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Allows a Prescriber to Cancel a Prescription


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Allows a Prescriber to Communicate Drug Administration Events